3.1 HIE Policy and Procedure for PHR

Section 3.2 Exchange – Interoperate HIE Policy and Procedure for PHR

Use this tool’s suggestions for policies and procedures if your office’s patients or their family members are actively engaged in using personal health records (PHR). Instructions for Use 1. Use the statements below to evaluate how your organization wants to support PHRs and/or their content, and then develop your policy. 2. As with any policy you develop, make sure it is approved by appropriate authorities within your organization, staff is educated, and policy compliance is enforced. PHR Acceptance Policy Options Consider one or a combination of the following policy options as you encourage your patients to adopt a PHR, and especially if your office supports a PHR service for its patients.

Option 1: PHR Data is a Personal Resource Personal health records (PHR) are valuable aids for patients and/or their families to use to maintain health information and to make personal health care decisions. Their content is not considered part of the paper-based or electronic health record system we maintain on behalf of our patients. 1. We recognize that the information contained in a PHR belongs exclusively to the patient and we will not attempt to append or accept any content directly from an individual’s PHR into our health record system without consideration as described below in #2. 2. Individuals should be encouraged to reference their PHRs when discussing their health care with their providers. Providers may summarize such information or request a copy of specific parts of the PHR for inclusion in our health record system if applicable. When a copy is made of specific information (even if it is a copy of content from another health care provider’s record), it will be marked “copy from ’s PHR, reviewed by .” 3. Should an individual request that our organization accept PHR content into our health record system, we will ask that the individual maintain his or her own PHR and use it for reference purposes. Individuals have the right to request an amendment to the health records we retain on their behalf. 4. An individual wishing to request an amendment to the existing content of the health record in our system should be referred to ______, who will process the request for amendment per HIPAA regulations. 5. In performing quality reviews of our health record system, information accepted from a PHR without authentication of a licensed health care professional will be deemed “signature deficient” and returned for completion. Cases of such acceptance of PHR content also will be brought to the attention of our documentation improvement program.

Section 3.2 Exchange – Interoperate – HIE Policy and Procedure for PHR - 1 Option 2: PHR Data is a Primary Source of Information for the Organization Personal health records are valuable aids for patients and/or their families to use to maintain health information and to make personal health care decisions. We support the development and use of PHRs in structured form, and will accept content derived from an electronic PHR into our health record system in the following manner: 1. In accordance with standards of health care practice, we will offer, via a secure portal directly connected to our information systems, the ability for our patients or their designated family member to update their contact and insurance information, enter structured health history information, add applicable substances to a current medication list, record dates and times of self-administered medication taken, record dates of visits to other health care providers, list immunizations, and provide other health information we determine to be appropriate and for which we provide a structure for receipt through the electronic information system. 2. Our secure portal will include specific information concerning how and when we will use the information supplied, especially indicating that it will not be accepted into our health record system until it has been reviewed, validated, and accepted by a licensed health care professional. Applicable health care professionals will receive notification of newly entered information from their designated patients via the dashboard or in-box feature in our information system. At that time, it must be reviewed, validated, and electronically signed by the health care professional. If they have any questions concerning its accuracy, an annotation stating “this information was supplied by the patient [or family representative] and cannot be verified” will be added to the health record. When patient/family-entered information is accepted into the health record by the health care professional, the patient’s/family’s authentication (date and time of entry and electronic signature) will be included with the information. 3. In performing quality reviews of our health record system, information accepted from a PHR without authentication of a licensed health care professional will be deemed “signature deficient” and returned for completion. Cases of such acceptance of PHR content also will be brought to the attention of our documentation improvement program.

Option 3: Support for Patient PHR Personal health records are valuable aids for patients or their families to use to maintain health information and to make personal health care decisions. As such, we supply a computer-based PHR which our patients or their family members may use at their discretion. 1. We will designate specific information that we will transfer to the PHR and make available for patients and/or their family members to use. The patient or family member has the right to authorize any other providers at any other health care organization to access the health information we have entered or any information the patient or family member has entered. 2. This PHR will be maintained by the patient or family member and information will be supplied as part of the user agreement indicating that it will not be considered part of our health record system. Should information entered into the PHR be desired to be transferred to our health record system, we will follow our policy on .

Adapted from Stratis Health’s Doctor’s Office Quality – Information Technology Toolkit, © 2005, developed by Margret\A Consulting, LLC. and produced under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.

For support using the toolkit Stratis Health  Health Information Technology Services 952-854-3306  [email protected] www.stratishealth.org

Section 3.2 Exchange – Interoperate – HIE Policy and Procedure for PHR - 3